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Friday 22 September 2023

Regulation is no silver bullet—culture change is more urgent and important

By Jon Restell

The Lucy Letby case demands a comprehensive and thoughtful response. Statutory regulation of managers may be a part of that, but won't be a quick fix. Right now, we need to tackle a culture that deters staff, patients and the public from raising concerns about NHS care.

Jon Restell portrait 2021

“It’s about culture, not regulation. Those managers cared about their reputations more than dealing with concerns.” Such was the assessment of a friend in the marketing industry watching the coverage of Lucy Letby’s murder trial and the alleged response of the Countess of Chester trust as evidence of her crimes emerged.

Whether or not it’s a fair assessment of those managers’ motivations must be left to the independent inquiry. But my friend’s reaction suggests a wider public awareness of the issues at stake. It also points to dissatisfaction with the early suggestions from policymakers that statutory regulation of managers is the silver bullet that will stop such terrible events happening again.

The Letby case requires a comprehensive, thoughtful response, of which statutory regulation may well be a part. But the Countess of Chester hospital was well-thicketed with regulation. Key protagonists such as the medical and nurse director were covered by exactly the type of personal regulation of both their management and clinical duties proposed by the Labour party and being considered by NHS England. Board members were covered by the annual fit and proper person test. The CQC inspected the leadership and management.

Effective regulation means standard setting, registration, training, revalidation and an independent body to judge managers who fall short. It will take time and money to establish, neither of which policymakers have shown much appetite for providing so far. Regulation will also trigger a much needed debate about the numbers and autonomy of managers in healthcare. Policymakers will stomach this even less.

There are limits to what remote and retrospective regulation can do. As former CQC boss David Behan was always at pains to say, regulation is only one of the pillars of quality healthcare, others such as commissioner behaviour, provider management, clinical professionalism and public voice and vigilance are equally important, if not sturdier, guarantors of day-to-day standards.

So how should we respond? How managers handle concerns is nearly always at the heart of cases that give rise to calls for more regulation. The culture of the NHS, particularly around the raising of concerns, is the more urgent and important issue. If NHS England had convened an urgent summit on handling concerns, rather than statutory regulation, there might be more confidence in the NHS’s corporate response.

MiP’s work with individual members suggests what makes for good culture. Effective managers set up and maintain systems to deal with concerns in real time while enabling appropriate anonymity. Most concerns can and should be dealt with locally as business as usual. But with more serious concerns and risks, it becomes critical that managers respond as a team, and in most hospital settings, this means general, nurse and medical managers working hand in glove. (Other settings, such as primary care or commissioning, have different and often hairier challenges, which need more thought, too.) Situations take a dive when it’s a lone manager or clinician trying to raise concerns and relying on formal whistleblowing procedures.

Open, multiple channels to the board are another important characteristic – ideally with non-executive directors taking responsibility for working with departments and services. Finally, leaders need to look for trouble rather than seek assurance. The late Andrew Foster, an experienced chief executive, used to wait round the corner after visiting a department, because he knew someone would probably come along who had not been able to say what they thought in front of other staff. We can work on such things right away. Dedicated managers across the NHS are reflecting on what to do in response to Letby. Let’s help them.

Regulation is no silver bullet. With resource and thought, it might help set standards and unlock the management capacity and autonomy the NHS needs. But the idea should not be used to give false assurance to an outraged public and grieving families. More urgent and important is our culture around handling concerns, which will only increase in the face of overwhelming demand on services and staff shortages. Practical guidance and leadership here would create the most confidence among worried members of the public, staff and managers.

  • Jon Restell is chief executive of Managers in Partnership.
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